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• Coronary artery disease (CAD)


  Atherosclerotic heart disease or ischemic heart disease
• CAD implies insufficient perfusion of the coronary arteries from an abnormal narrowing of the vessels, leading to insufficient oxygen delivery to the myocardial tissue
• Understanding risk factors for CAD


  • Most important in establishing a diagnosis in cases of chest pain with equivocal or uncertain histories
• Menstruating women virtually never have myocardial infarctions
• Most clearly agreed-upon risk factors for CAD


  • Diabetes mellitus
  • Tobacco smoking
  • Hypertension
  • Hyperlipidemia
  • Age above 45 in men and above 55 in women
  • Family history of premature coronary artery disease
• Premature coronary disease


  Defined as being in a family member who is a Male relative under 55 or Female relative under 65
• The most frequent mistake in risk factor questions involves family history: mistaking CAD in elderly relatives, even if they are the patient's parents, as a risk for the patient
• The worst risk factor for CAD is diabetes mellitus, but the most common risk is hypertension
• Elevations in triglyceride levels are potentially dangerous, but this is not as reproducible in terms of poor outcome as the elevated LDL
• Hypertension is more common than diabetes with about 20% of the total population, or 60 million people, suffering from hypertension
• Nearly half of these people do not currently know that they are hypertensive
• Marked elevation in LDL is by far the most dangerous portion of a lipid profile for a patient
• A low HDL is also associated with a poor long-term prognosis, but is not as dangerous as an elevated LDL
• Patients with diabetes have the highest rates of CAD when followed over a long period of time such as 10 years
• Elevations in triglyceride levels are potentially dangerous, this is not as reproducible in terms of poor outcome as the elevated LDL. The proper treatment of an isolated elevation of triglyceride level is not as clearly beneficial as treatment of an elevated LDL level
• Hypertension is more common than diabetes with about 20% of the total population, or 60 million people, suffering from hypertension. Nearly half of these people do not currently know that they are hypertensive
• Marked elevation in LDL is by far the most dangerous portion of a lipid profile for a patient. A low HDL is also associated with a poor long-term prognosis, but is not as dangerous as an elevated LDL
• Obesity, particularly that resulting in increasing abdominal girth, is associated with increased cardiac mortality. However, much of the danger of obesity is from its association with other abnormalities such as hyperlipidemia, diabetes, and hypertension
• Smoking cessation results in the greatest immediate improvement in patient outcomes for CAD. Within a year after stopping smoking, the risk of CAD decreases by 50%. Within 2 years after stopping smoking, the risk is reduced by 90%
• Less Reliable but Probable Risk Factors for CAD


  • Physical inactivity
  • Excess alcohol ingestion
  • Insufficient fruits and vegetables in the diet
  • Emotional stress
  • Elevated cardiac CT scan calcium scores
  • Positron emission tomography (PET) scanning
• Increased physical activity and exercise reliably lower all-cause mortality, but physical inactivity is not as severe a risk for coronary disease as diabetes and hypertension
• Atheroembolism


  Occurs when an atherosclerotic plaque is disrupted and cholesterol crystals and debris are showered into the circulation, leading to partial or total occlusion of arterioles with resultant tissue or organ ischemia
• Atheroembolism is most commonly seen as a complication of cardiac catheterization and other vascular procedures
• Clinical manifestations of atheroembolism


  • Can be immediate or delayed (>30 days after inciting event)
  • Atherosclerotic plaques in the aortic arch can embolize to the brain and cause cerebral infarction
  • Diffuse showering of emboli into the peripheral circulation can cause intestinal ischemia, gastrointestinal bleeding, pancreatitis, and acute kidney injury
• Skin manifestations of atheroembolism


  • "Blue toe syndrome" (cyanotic toes with intact pulses)
  • Livedo reticularis (reticular, lacy skin discoloration/erythema that blanches on pressure)
  • Gangrene
  • Ulcers
• Examination of the retina may show Hollenhorst plaques, bright, yellow, refractile plaques in the retinal artery, which indicate a proximal source such as the internal carotid artery
• Treatment of atheroembolism


  Supportive and includes statin therapy for risk factor reduction and prevention of recurrent cholesterol embolism
• Takotsubo cardiomyopathy


  A type of non-ischemic cardiomyopathy characterized by hypokinesis of the mid and apical segments and hyperkinesis of the basal segments of the left ventricle, resulting in systolic dysfunction and reduced ejection fraction
• Cause of Takotsubo cardiomyopathy


  Likely caused by a surge of catecholamines in the setting of physical or emotional stress (death of a loved one)
• Takotsubo cardiomyopathy usually affects postmenopausal women and resolves on its own within several weeks
• Characteristic appearance of Takotsubo cardiomyopathy


  The resulting segmental LV dysfunction creates a characteristic balloon shape on echocardiogram that mimics that of an octopus trap (takotsubo means "octopus trap" in Japanese)
• Triggers for Takotsubo cardiomyopathy


  • Divorce, financial issues, earthquake, lightning strike, and hypoglycemia
• For every 100 people presenting to the emergency department with chest pain, less than 10% end up having a myocardial infarction as a cause of the chest pain. Fifty percent or more have no cardiac disease at all
• The most common cause of chest pain that is not ischemic in nature is gastrointestinal disorders
• Characteristics of Ischemic Pain


  • Duration: Stable angina: >2 to <10 min, ACS: >10 to 30 min
  • Location: Substernal
  • Provoking factors: Physical activity, cold, emotional stress
  • Alleviating factors: Rest
  • Quality: Squeezing, tightness, heaviness, pressure, burning, aching (NOT: sharp, pins, stabbing, knifelike)
  • Radiation: Neck, lower jaw & teeth, arms, shoulders
  • Associated symptoms: SOB, nausea, diaphoresis, dizziness, lightheadedness, fatigue
• When a patient has chest pain, and the etiology is not likely to be cardiac ischemia, the most likely cause is some type of gastrointestinal (GI) disorder such as GERD
• Other common GI disorders associated with chest pain


  • Ulcer disease
  • Cholelithiasis
  • Duodenitis
  • Gastritis
• Ischemic pain


  Dull or "sore", Squeezing or pressure-like
• Qualities of pain that go against ischemia


  Sharp ("knifelike") or pointlike, Lasts for a few seconds
• Ischemic pain is not tender, positional, or pleuritic